Provider Demographics
NPI:1720173180
Name:NISSEN, PHILLIP CRAIG (LCSW-C)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:CRAIG
Last Name:NISSEN
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 KNIGHTS ISLAND ROAD
Mailing Address - Street 2:
Mailing Address - City:EARLEVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21919
Mailing Address - Country:US
Mailing Address - Phone:410-275-1686
Mailing Address - Fax:410-642-1852
Practice Address - Street 1:1H CIRCLE DRIVE
Practice Address - Street 2:
Practice Address - City:PERRY POINT
Practice Address - State:MD
Practice Address - Zip Code:21902
Practice Address - Country:US
Practice Address - Phone:410-642-2411
Practice Address - Fax:410-642-1852
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD035631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical